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Flu Preparations: When It's Good to Wing It

Detailed preparedness plans drawn up in the past five years have been a boon for officials fighting the outbreak of swine flu. But not everyone is reading from the same page, as was clear at press conferences held today in the United States, Sweden, and Switzerland. In part, that’s because as helpful as preparedness plans can be, “microbes don’t read the plan, and you need to move away from the plan pretty soon after day one,” said Richard Besser, acting director of the U.S. Centers for Disease Control and Prevention.

As CDC, the World Health Organization in Geneva, and the European Centre for Disease Prevention and Control (ECDC) in Stockholm made clear, countries—and even states and cities within countries—are tailor-making responses to their outbreaks. Perspectives differ about containment strategies, including school closings, travel restrictions, and airport screenings. Decisions vary about when to report cases. And many locales still have only limited, if any, ability to test for the novel virus causing the outbreak. There’s even some debate about whether to call the outbreak “swine flu” or not, with WHO and others renaming it the less catchy "H1N1 virus," and some calling it the “Mexican flu.”

More countries will get to stick their fingers in this pie because the virus is spreading rapidly. Lab-confirmed cases are up to 236 from 148 yesterday; and three more European countries have joined the list: the Netherlands, France (with a probable case), and Switzerland. Peru and Costa Rica are now flu zones, too. Even a member of President Barack Obama’s security team is suspected of catching swine flu during a recent visit to Mexico with the president. Because of this spread, Angus Nicoll, head of ECDC’s influenza program, said today that it’s “inevitable” that WHO will raise the alert level from pandemic phase 5 to 6, and “it’s just a question of when that will happen.” But WHO said the situation hasn’t changed yet: “There is nothing that epidemiologically suggests today that we should be moving towards phase 6,” said Keiji Fukuda, WHO’s assistant director-general for health security and environment, in a briefing.

“There’s a backlog of several thousand specimens that need to be tested,” said Fukuda.

Thanks to some additional testing, the number of confirmed cases in Mexico jumped to 97 from 26, but the number of deaths remains at 7. Officials expect those numbers to rise as the backlog is cleared.

Meanwhile, senior health officials from different countries are attempting to coordinate disease surveillance and response with one another, spending hours on transnational conference calls even while separately quibbling over details such as travel restrictions (considered useless by CDC and WHO, but recommended by some countries), and the importance of antiviral drugs. Identifying every case is also a priority, as is determining when to limit social gatherings, as Mexico has been doing. “Countries are looking very hard for outbreaks of infections” and governments “are preparing business continuity plans,” said Nicoll. That means considering what types of businesses or government operations could briefly be shut down, such as courts, and which ones, like the shipping of food, must stay open.

Another source of confusion is the value of computer models in anticipating the virus’s path. Besser said CDC has used models to look at questions such as the value of closing borders but stressed that they had their limits. “As many modelers as you have, you'll have that number of estimates,” he said. Nicoll said that at this stage, we don’t know enough about this virus to reliably model it. Even so, that hasn’t stopped “everybody, at this point” from seeking modeling data, he noted.

Meanwhile, U.S. Vice President Joseph Biden caused a stir earlier today when he said he wouldn’t want to travel by plane or subway, contradicting his boss’s advice and prompting quick clarification from Biden’s office.

Health ministers from the European Union met today in Luxembourg about the outbreak response, while another meeting was under way in London to discuss whether vaccine manufacturers should shift efforts to producing a vaccine against the swine H1N1 instead of a seasonal flu vaccine—an exceedingly tough call given the uncertainties around H1N1 and how dangerous it is, and is likely to become.

CDC, racing to sequence the virus from those infected, said it’s seeing “slight changes” in its genetic makeup, but, said Besser, agency scientists don’t know what that means.